Continuous Ambulatory Peritoneal Dialysis and Clinical Outcomes in Patients With Refractory Congestive Heart Failure

Introduction and objectives

Peritoneal dialysis has been proposed as a therapeutic alternative for patients with refractory congestive heart failure. The objective of this study was to assess its effect on long-term clinical outcomes in patients with advanced heart failure and renal dysfunction.

Methods

A total of 62 patients with advanced heart failure (class III/IV), renal dysfunction (glomerular filtration<60 mL/min/1.73 m²), persistent fluid congestion despite loop diuretic treatment and at least 2 previous hospitalizations for heart failure were invited to participate in a continuous ambulatory peritoneal dialysis program. Of these, 34 patients were excluded and adjudicated as controls. The most important reasons for exclusion were refusal to participate, inability to perform the technique and abdominal wall defects. The primary endpoint was all-cause mortality and the composite of death/readmission for heart failure. To account for baseline imbalance, a propensity score was estimated and used as a weight in all analyses.

Results

The peritoneal dialysis (n=28) and control groups (n=34) were alike in all baseline covariates. During a median follow-up of 16 months, 39 (62.9%) died, 21 (33.9%) patients were rehospitalization for heart failure, and 42 (67.8%) experienced the composite endpoint. In the propensity score-adjusted models, peritoneal dialysis (vs control group) was associated with a substantial reduction in the risk of mortality using complete follow-up (hazard ratio=0.40; 95% confidence interval, 0.21-0.75; P=.005), mortality using days alive and out of hospital (hazard ratio=0.39; 95% confidence interval, 0.21-0.74; P=.004) and the composite endpoint (hazard ratio=0.32; 95% confidence interval, 0.17-0.61; P=.001).

Conclusions

In refractory congestive heart failure with concomitant renal dysfunction, peritoneal dialysis was associated with long-term improvement in clinical outcomes.     

Red blood cell distribution width adds prognostic value for outpatients with chronic heart failure

Introduction and objectives

Red blood cell distribution width has emerged as a new prognostic biomarker in cardiovascular diseases. Its additional value in risk stratification of patients with chronic heart failure has not yet been established.

Methods

A total of 698 consecutive outpatients with chronic heart failure were studied (median age 71 years [interquartile range, 62-77], 63% male, left ventricular ejection fraction 40 [14]%). On inclusion, the red cell distribution width was measured and clinical, biochemical, and echocardiographic variables were recorded. The median follow-up period was 2.5 years [interquartile range 1.2-3.7].

Results

A total of 211 patients died and 206 required hospitalization for decompensated heart failure. Kaplan-Meier analysis showed an increase in the probability of death and hospitalization for heart failure with red cell distribution width quartiles (log rank, P<.001). A ROC analysis identified a red cell distribution width of 15.4% as the optimal cut-off point for a significantly higher risk of death (P<.001; hazard ratio=2.63; 95% confidence interval, 2.01-3.45) and hospitalization for heart failure (P<.001; hazard ratio=2.37; 95% confidence interval, 1.80-3.13). This predictive value was independent of other covariates, and regardless of the presence or not of anaemia. Importantly, the addition of red cell distribution width to the clinical risk model for the prediction of death or hospitalization for heart failure at 1 year had a significant integrated discrimination improvement of 33% (P<.001) and a net reclassification improvement of 10.3% (P=.001).

Conclusions

Red cell distribution width is an independent risk marker and adds prognostic information in outpatients with chronic heart failure. These findings suggest that this biological measurement should be included in the management of these patients.Full English text available from:www.revespcardiol.org     

Supervivencia de pacientes ambulatorios con insuficiencia cardiaca crónica del área mediterránea. Un estudio de base poblacional

Introduction and objectives

Scarce research has been performed in ambulatory patients with chronic heart failure in the Mediterranean area. Our aim was to describe survival trends in our target population and the impact of prognostic factors.

Methods

We carried out a population-based retrospective cohort study in Catalonia (north-east Spain) of 5659 ambulatory patients (60% women; mean age 77 [10] years) with incident chronic heart failure. Eligible patients were selected from the electronic patient records of primary care practices from 2005 and were followed-up until 2007.

Results

During the follow-up period deaths occurred in 950 patients (16.8%). Survival after the onset of chronic heart failure at 1, 2, and 3 years was 90%, 80%, 69%, respectively. No significant differences in survival were found between men and women (P=.13). Cox proportional hazard modelling confirmed an increased risk of death with older age (hazard ratio=1.06; 95% confidence interval, 1.06-1.07), diabetes mellitus (hazard ratio=1.53; 95% confidence interval, 1.33-1.76), chronic kidney disease (hazard ratio=1.73; 95% confidence interval, 1.45-2.05), and ischemic heart disease (hazard ratio=1.18; 95% confidence interval, 1.02-1.36). Hypertension (hazard ratio=0,73; 95% confidence interval, 0,64-0,84) had a protective effect.

Conclusions

Service planning and prevention programs should take into consideration the relatively high survival rates found in our area and the effect of prognostic factors that can help to identify high risk patients.Full English text available from:www.revespcardiol.org/en     

Cronobiología de la muerte en insuficiencia cardiaca

Introduction and objectives

In the general population, heart events occur more often during early morning, on Mondays, and during winter. However, the chronobiology of death in heart failure has not been analyzed. The aim of this study was to determine the circadian, day of the week, and seasonal variability of all-cause mortality in chronic heart failure.

Methods

This was an analysis of all consecutive heart failure patients followed in a heart failure unit from January 2003 to December 2008. The circadian moment of death was analyzed at 6-h intervals and was determined by reviewing medical records and by information provided by the relatives.

Results

Of 1196 patients (mean [standard deviation] age, 69 [13] years; 62% male), 418 (34.9%) died during a mean (standard deviation) follow-up of 29 (21) months. Survivors were younger, had higher body mass index, left ventricular ejection fraction, glomerular filtration rate, hemoglobin and sodium levels, and lower Framingham risk scores, amino-terminal pro-B type natriuretic peptide, troponin T, and urate values. They were more frequently treated with angiotensin receptor blockers, beta-blockers, mineralocorticoids receptor antagonists, digoxin, nitrates, hydralazine, statins, loop diuretics, and thiazides. The analysis of the circadian and weekly variability did not reveal significant differences between the four 6-h intervals or the days of the week. Mortality occurred more frequently during the winter (30.6%) compared with the other seasons (P = .024).

Conclusions

All cause mortality does not follow a circadian pattern, but a seasonal rhythm in patients with heart failure. This finding is in contrast to the circadian rhythmicity of cardiovascular events reported in the general population.Full English text available from:www.revespcardiol.org/en     

Importancia clínica de la insuficiencia cardiaca congestiva en la endocarditis protésica. Estudio multicéntrico de 257 pacientes

Introduction and objectives

There have been no studies conducted in the past that focus on the significance of congestive heart failure in patients with prosthetic valve endocarditis. We studied the incidence of congestive heart failure in patients with prosthetic valve endocarditis and analyzed its profile. In this study, we addressed the prognostic significance of heart failure in patients with prosthetic valve endocarditis and analyzed its outcome based on chosen therapeutic strategies.

Methods

A total of 639 episodes of definite left-sided endocarditis were prospectively enrolled. Of them, 257 were prosthetic. Of the 257 episodes, 145 (56%) were diagnosed with heart failure. We compared the profiles of patients with prosthetic valve endocarditis based on the presence of heart failure, and performed a multivariate logistic regression model to establish the prognostic significance of heart failure in patients with prosthetic valve endocarditis and identified the prognostic factors of in-hospital mortality in these patients.

Results

Persistent infection (odds ratio=3.6; 95% confidence interval, 1.9-6.9) and heart failure (odds ratio=3; 95% confidence interval, 1.5-5.8) are the strongest predictive factors of in-hospital mortality in patients with prosthetic valve endocarditis. The short-term determinants of prognosis in patients with prosthetic valve endocarditis and heart failure are persistent infection (odds ratio=2.8; 95% confidence interval, 1.2-6.5), aortic involvement (odds ratio=2.5; 95% confidence interval, 1.1-5.8), abscess (odds ratio=3.6; 95% confidence interval, 1.4-9.5), diabetes mellitus (odds ratio=2.9; 95% confidence interval, 1.1-7.7), and cardiac surgery (odds ratio=0,2; 95% confidence interval, 0,1-0,5).

Conclusions

The incidence of heart failure in patients with prosthetic valve endocarditis is very high. Heart failure increases the risk of in-hospital mortality by threefold in patients with prosthetic valve endocarditis. Persistent infection, aortic involvement, abscess, and diabetes mellitus are the independent risk factors associated with mortality in patients with prosthetic valve endocarditis and heart failure; however, cardiac surgery is shown to decrease mortality in these patients.Full English text available from:www.revespcardiol.org/en     

Pérdida de estimulación biventricular continua en pacientes con terapia de resincronización cardiaca: incidencia,causas y resultados

Introduction and objectives

In recent years, implantation of cardiac resynchronization therapy devices has significantly increased. The benefits of this therapy are directly related to the maintenance of continuous biventricular pacing. This study analyzed the incidence, causes, and outcomes of loss of continuous biventricular pacing, and the approach adopted.

Methods

We analyzed the clinical and follow-up data of a series of consecutive patients from a single center who underwent implantation of a cardiac resynchronization therapy device.

Results

The study included 136 patients. During a mean follow-up of 33.4 months, loss of continuous biventricular pacing occurred in 45 patients (33%). The most common causes included atrial tachyarrhythmias (21.3%), lead macrodislodgement (18%), and loss of left ventricular capture (13.1%). In most patients (88.5%), loss of continuous biventricular pacing was transient and correctable, and occurred earlier in the follow-up when the cause was lead macrodislodgement, oversensing, or extracardiac stimulation. There were no significant differences in mortality between patients with and without loss of continuous biventricular pacing (P=.88).

Conclusions

Despite technical advances in cardiac resynchronization therapy, loss of continuous biventricular pacing is common; however, this loss can usually be corrected. In most patients, continuous biventricular pacing can be ensured by close monitoring and follow-up and a proactive approach.Full English text available from:www.revespcardiol.org/en     

Tratamiento anticoagulante en pacientes con insuficiencia cardiaca por disfunción sistólica y ritmo sinusal: análisis del registro REDINSCOR

Introduction and objectives

In patients with heart failure, left ventricular ejection fraction ≤35% and sinus rhythm without conditions such as atrial fibrillation, thrombus or history of thromboembolic events, the use of anticoagulation is controversial. Our objective was to evaluate the anticoagulation strategy in these patients, variables associated with its use, and its effects on various cardiovascular events.

Methods

Of the patients included in the REDINSCOR registry with left ventricular ejection fraction ≤35% and sinus rhythm without other anticoagulation indications (including patients with heart failure from 19 Spanish centres), we compared those who received this treatment with the remaining patients.

Results

Between 2007 and 2010, 2263 patients were included, of whom 902 had left ventricular ejection fraction ≤35% and sinus rhythm. Of these, 237 (26%) were receiving anticoagulation therapy. Variables associated with this treatment were a lower left ventricular ejection fraction, ischemic etiology, advanced functional class, wider QRS, larger left atrial diameter, and hospitalization. After 21(11-32) months of median follow-up, there were no significant differences in total mortality (14% versus 12.5%) or stroke (0.8% versus 0.9%). A propensity score adjusted multivariate analysis showed a reduction in a combined end-point including cardiac death, heart transplantation, coronary revascularization, and cardiovascular hospitalization (hazard ratio: 0.74; 95% confidence interval, 0.56-0.97; P=.03) in patients receiving anticoagulation therapy. No information regarding bleeding was collected in the follow-up.

Conclusions

In a large and contemporary series of patients with heart failure, left ventricular ejection fraction ≤35% and sinus rhythm, 26% received anticoagulation therapy. This was not associated with lower mortality or stroke incidence, although there was a reduction in major cardiac events.Full English text available from:www.revespcardiol.org     

Interleucina 6 y proteína C reactiva ultrasensible para la predicción de la evolución clínica en síndromes coronarios agudos sin elevación del segmento ST

Introduction and objectives

High baseline levels of interleukin-6 and C-reactive protein confer an increased risk of mortality in non-ST-segment elevation acute coronary syndrome. The aim of the study was to determine whether serial measurements of interleukin-6 and high-sensitivity C-reactive protein provide additional information to baseline measurements for risk stratification of non-ST-segment elevation acute coronary syndrome.

Methods

Two hundred and sixteen consecutive patients with non-ST-segment elevation acute coronary syndrome were prospectively included. Blood samples were obtained within 24 h of hospital admission and at 30 days of follow-up. The endpoint was a composite of all-cause death, nonfatal myocardial infarction, or acute decompensated heart failure.

Results

Both interleukin-6 and high-sensitivity C-reactive protein levels decreased from day 1 to day 30, regardless of adverse events (both P<.001). Interleukin-6 levels at 2 time points (interleukin-6 day 1, per pg/mL; hazard ratio=1.006, 95% confidence interval, 1.002-1.010; P=.002 and interleukin-6 day 30, per pg/mL; hazard ratio=1.047, 95% confidence interval, 1.021-1.075; P<.001) were independent predictors of adverse events, whereas high-sensitivity C-reactive protein day 1 and high-sensitivity C-reactive protein day 30 levels were not. Patients with interleukin-6 day 1≤8.24 pg/mL and interleukin-6 day 30≤4.45 pg/mL had the lowest event rates (4.7%), whereas those with both above the median values had the highest event rates (35%). After addition of interleukin-6 day 30 to the multivariate model, C-index increased from 0.71 (95% confidence interval, 0.63-0.78) to 0.80 (95% confidence interval, 0.72-0.86), P=.042, and net reclassification improvement was 0.39 (95% confidence interval, 0.14-0.64; P=.002).

Conclusions

In this population, both interleukin-6 and high-sensitivity C-reactive protein concentrations decreased after the acute phase. Serial samples of interleukin-6 concentrations improved the prognostic risk stratification of these patients.Full English text available from:www.revespcardiol.org/en     

Fracción aminoterminal del propéptido natriurético cerebral y troponina ultrasensible en el dolor torácico agudo de origen incierto. Un subestudio del estudio PITAGORAS

Introduction and objectives

High-sensitivity troponin assays have improved the diagnosis of acute coronary syndrome in patients presenting with chest pain and normal troponin levels as measured by conventional assays. Our aim was to investigate whether N-terminal pro-brain natriuretic peptide provides additional information to troponin determination in these patients.

Methods

A total of 398 patients, included in the PITAGORAS study, presenting to the emergency department with chest pain and normal troponin levels as measured by conventional assay in 2 serial samples (on arrival and 6 h to 8 h later) were studied. The samples were also analyzed in a central laboratory for high-sensitivity troponin T (both samples) and for N-terminal pro-brain natriuretic peptide (second sample). The endpoints were diagnosis of acute coronary syndrome and the composite endpoint of in-hospital revascularization or a 30-day cardiac event.

Results

Acute coronary syndrome was adjudicated to 79 patients (20%) and the composite endpoint to 59 (15%). When the N-terminal pro-brain natriuretic peptide quartile increased, the diagnosis of acute coronary syndrome also increased (12%, 16%, 23% and 29%; P=.01), as did the risk of the composite endpoint (6%, 13%, 16% and 24%; P=.004). N-terminal pro-brain natriuretic peptide elevation (>125 ng/L) was associated with both endpoints (relative risk= 2.0; 95% confidence interval, 1.2-3.3; P=.02; relative risk=2.4; 95% confidence interval, 1.4-4.2; P=.004). However, in the multivariable models adjusted by clinical and electrocardiographic data, a predictive value was found for high-sensitivity T troponin but not for N-terminal pro-brain natriuretic peptide.

Conclusions

In low-risk patients with chest pain of uncertain etiology evaluated using high-sensitivity T troponin, N-terminal pro-brain natriuretic peptide does not contribute additional predictive value to diagnosis or the prediction of short-term outcomes.Full English text available from:www.revespcardiol.org/en.     

El análisis del flujo aórtico por ecocardiografía Doppler es útil en la estratificación pronóstica de los pacientes con estenosis aórtica grave con fracción de eyección normal

Introduction and objectives

The prognosis of patients with severe aortic stenosis, low aortic gradient and preserved ejection fraction is controversial. Our study analyzed the prognosis of these patients and its relation to pressure gradient and aortic valve flow.

Methods

We performed a retrospective cohort study of 363 consecutive patients with severe aortic stenosis and preserved ejection fraction, divided into 4 groups, based on the presence of a systolic volume index greater or lower than 35 mL/m² and the presence of a mean aortic gradient greater or lower than 40 mmHg. Group I: normal flow, high gradient (n=169, 47%); group II: normal flow, low gradient (n=98, 27%); group III: low flow, high gradient (n=54, 15%), and group IV: low flow, low gradient (n=42, 12%). The primary endpoint was overall mortality.

Results

Independent risk factors for mortality were age (hazard ratio=1.04; 95% confidence interval, 1.01-1.08) and atrial fibrillation (hazard ratio=2.21; 95% confidence interval, 1.24-3.94). Surgical treatment was associated with longer survival in all groups (hazard ratio=0.25; 95% confidence interval, 0.13-0.49). Mortality was higher in patients with low flow than in those with with normal flow (26.6% vs 13.6%; P=.004). The most favorable mean prognosis was found in group II (hazard ratio=0.4; 95% confidence interval, 0.2-0.9).

Conclusions

Patients with severe aortic stenosis, normal ejection fraction and low aortic flow have a worse prognosis. Analysis of aortic flow by Doppler echocardiography is useful in risk stratification and therapeutic decision-making in patients with aortic stenosis.Full English text available from:www.revespcardiol.org/en.     

Influencia de una estrategia de alerta multidisciplinaria en la mortalidad por endocarditis infecciosa izquierda

Introduction and Objectives

Mortality from left-sided infective endocarditis remains very high. The aim of this study was to assess the impact of a multidisciplinary alert strategy (AMULTEI), based on clinical, echocardiographic and microbiological findings, implemented in 2008 in a tertiary hospital.

Methods

Cohort study comparing our historical data series (1996-2007) with the number of patients diagnosed with left-sided endocarditis from 2008-2011 (AMULTEI).

Results

The AMULTEI cohort included 72 patients who were compared with 155 patients in the historical cohort. AMULTEI patients were significantly older (62.5 vs 57.9 years in the historical cohort; P=.047) and had higher comorbidity (Charlson index, 3.33 vs 2.58 in the historical cohort; P=.023). There was also a trend toward more enterococcal etiology in the AMULTEI group (20.8% vs 11.6% in the historical cohort; P=.067). In the AMULTEI group, early surgery was more frequently performed (48.6% vs 23.2%; P<.001) during hospitalization, the incidence of septic shock was significantly lower (9.7% vs 24.5%; P=.009) and there was a trend toward reductions in neurological complications (19.4% vs 29.0%; P=.25) and severe heart failure (12.5% vs 18.7%; P=.24). In-hospital mortality and mortality during the first month of follow-up were significantly lower in the AMULTEI group (16.7% vs 36.1%; P=.003).

Conclusions

Despite the trend toward older age and more comorbidity measured by the Charlson index, early mortality was significantly lower in patients treated with the AMULTEI strategy.Full English text available from:www.revespcardiol.org/en     

Factors associated with knowledge and control of arterial hypertension in the Canary Islands

Introduction and objectives

To analyze the factors associated with knowledge and control of hypertension in the adult population of the Canary Islands (18-75 years).

Methods

We recruited a random sample of the general population aged ≥18 years. Hypertension was defined as systolic/diastolic blood pressure ≥140/90 mmHg or known hypertension (self-declared, or controlled hypertension <140/90 mmHg). The bivariate association of known and controlled hypertension with age, sex, anthropometry, serum lipids, medication, and lifestyle was corroborated by adjusting a multivariate logistic model.

Results

We included 6675 participants. The prevalence of hypertension was higher in men (40% vs 31%, P<.001), who also had a lower frequency of treated and controlled hypertension. Female sex (P<.001), age ≥55 years (P<.001), obesity (P<.001), and diabetes (P<.001) were associated with known hypertension. The modifiable factors that, in spite of treatment, increased the risk of poor control of hypertension were alcohol consumption (>30 g/day, odds ratio [OR]=2.4, P<.001; >15-≤30 g/day, OR=2, P=.009; >5-≤15, g/day, OR=1.83, P=.004), obesity (body mass index ≥30, OR=2, P=.003; >24.9-<30, OR=1.7, P=.024), serum cholesterol >250 mg/dL (OR=1.6, P=.006) and elevated heart rate (>80 bpm, OR=1.45, P=.045; >70-≤80 bpm, OR=1.36, P=.038).

Conclusions

The awareness of hypertension increases with frequent use of the health system and with factors associated with known hypertension: female sex, age, underlying health problems. The modifiable factors associated with poor control of known hypertension are alcohol consumption, obesity, elevated heart rate, and hypercholesterolemia.Full English text available from:www.revespcardiol.org     

Heart failure survival score in patients with Chagas disease: correlation with functional variables

Introduction and objectives

Chagas disease is a prevalent cause of heart failure in Latin America, and its prognosis is worse than other etiologies. The Heart Failure Survival Score has been used to assess prognosis in patients with heart failure; however, this score has not yet been studied in patients with Chagas cardiopathy.

Methods

The Heart Failure Survival Score was calculated in 55 patients with severe left ventricular systolic dysfunction due to Chagas disease. Correlations were assessed between the Heart Failure Survival Score and variables obtained from, cardiopulmonary exercise tests, quality-of-life measures, and 6-minute walking tests.

Results

Patients were distributed among New York Heart Association classes II–IV; 89% were taking angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, 62% were taking beta-blockers, 86% were taking diuretics, and 74% were taking aldosterone receptor blockers. The mean Heart Failure Survival Score was 8.75 (0.80). The score correlated well with cardiopulmonary test variables such as peak oxygen uptake (0.662; P<.01), oxygen uptake at the anaerobic threshold (0.644; P<.01), ventilation carbon dioxide efficiency slope (−0.417; P<.01), oxygen pulse (0.375; P<.01), oxygen uptake efficiency slope (0.626; P<.01), 6-minute walking test (0.370; P<.01), left ventricle ejection fraction (0.650; P=.01), and left atrium diameter (−0.377; P<.01). There was also a borderline significant correlation between the Heart Failure Survival Score and quality of life (−0.283; P<.05).

Conclusions

In heart failure patients with Chagas disease, the Heart Failure Survival Score correlated well with the main prognostic functional test variables.Full English text available from:www.revespcardiol.org     

Beneficio clínico de la terapia de resincronización cardiaca con desfibrilador para pacientes con fracción de eyección > 35% por resonancia magnética

Introduction and objectives

Cardiac resynchronization therapy with a defibrillator prolongs survival and improves quality of life in advanced heart failure. Traditionally, patients with ejection fraction > 35% estimated by echocardiography have been excluded. We assessed the prognostic impact of this therapy in a group of patients with severely depressed systolic function as assessed by echocardiography but with an ejection fraction > 35% as assessed by cardiac magnetic resonance.

Methods

We analyzed consecutive patients admitted for decompensated heart failure between 2004 and 2011. The patients were in functional class II-IV, with a QRS ≥ 120 ms, ejection fraction ≤ 35% estimated by echocardiography, and a cardiac magnetic resonance study. We included all patients (n = 103) who underwent device implantation for primary prevention. Ventricular arrhythmia, all-cause mortality and readmission for heart failure were considered major cardiac events. The patients were divided into 2 groups according to systolic function assessed by magnetic resonance.

Results

The 2 groups showed similar improvements in functional class and ejection fraction at 6 months. We found a nonsignificant trend toward a higher risk of all-cause mortality in patients with systolic function ≤ 35% at long-term follow-up. The presence of a pattern of necrosis identified patients with a worse prognosis for ventricular arrhythmias and mortality in both groups.

Conclusions

We conclude that cardiac resynchronization therapy with a defibrillator leads to a similar clinical benefit in patients with an ejection fraction ≤ 35% or > 35% estimated by cardiac magnetic resonance. Analysis of the pattern of late gadolinium enhancement provides additional information on arrhythmic risk and long-term prognosis.Full English text available from:www.revespcardiol.org/en     

Actitud y eficacia de los cardiólogos frente al tabaquismo de los pacientes tras un síndrome coronario agudo

Introduction and objectives

Smoking is one of the most prevalent risk factors in acute coronary syndrome patients. The aim of this study was to assess the attitudes of cardiologists to the smoking habits of these patients

Methods

A prospective multicenter registry of acute coronary syndrome patients. The primary endpoint was defined as smoking abstinence and the secondary endpoint as the incidence of all-cause mortality or nonfatal myocardial infarction.

Results

The study population included 715 patients; 365 were current smokers. During follow-up (median, 375,0 days [interquartile range, 359.3-406.0 days]), 110 patients (30.6%) received smoking cessation support (19.7% at hospital discharge and 37.6% at month 3), specialized units and varenicline being the strategies most frequently used. No clinical differences were observed between patients who received smoking cessation support and those who did not, except for a higher prevalence of previous coronary heart disease in those who received support. In the multivariate analysis, the only variable independently associated with receiving smoking cessation support was previous coronary heart disease (odds ratio =3.16; 95% confidence interval, 1.64-6.11; P<.01). The abstinence rate was 72.3% at month 3 and 67.9% at 1 year; no differences were observed between the patients who received smoking cessation support and those who did not. During follow-up, a nonsignificant trend toward a lower incidence of the secondary endpoint was observed among the patients who were smokers at the time of acute coronary syndrome and who achieved abstinence (P=.07).

Conclusions

Use of smoking cessation support strategies is limited in acute coronary syndrome patients and is more widespread among those with previous coronary heart disease.Full English text available from:www.revespcardiol.org     

Renal insufficiency and vascular complications after primary angioplasty via femoral route. Impact of vascular closure devices use

Introduction and objectives

We sought to determine the incidence of vascular complications in patients with chronic kidney disease undergoing primary angioplasty via the femoral route; we also evaluated the safety and efficacy of the use of vascular closure devices in this setting.

Methods

Registry of 527 patients undergoing primary angioplasty via the femoral route from January 2003 to December 2008. Chronic kidney disease was defined as creatinine clearance less than 60 mL/min. The primary endpoint was the presence of major vascular complications.

Results

Baseline chronic kidney disease was observed in 166 (31.5%) patients. Patients with chronic kidney disease experienced higher rates of major vascular complications compared to those without worsening of renal function (8.4% vs 4.2%; P=.045), especially those requiring transfusion (6.6% vs 1.9%; P=.006). Among patients with chronic kidney disease, 129 (77.7%) received a vascular closure device and manual compression was used in 37 patients (22.3%). The risk of major vascular complications was significantly lower with vascular closure device use compared to manual compression (4.7% vs 21.6%; P=.003). Multivariable logistic regression analysis showed that the use of a vascular closure device was independently associated with a decreased risk of major vascular complications in patients with chronic kidney disease undergoing primary angioplasty (odds ratio=0.11; 95% confidence interval, 0.03-0.41; P=.001).

Conclusions

Patients with chronic kidney disease undergoing primary angioplasty via the femoral route experience higher rates of major vascular complications. The use of vascular closure devices in this group of patients is safe and is associated with lower rates of major vascular complications compared to manual compression.Full English text available from:www.revespcardiol.org     

Stents liberadores de rapamicina sin polímero frente a stents liberadores de paclitaxel con polímero: un análisis de datos de pacientes procedentes de ensayos aleatorizados

Introduction and objectives

The angiographic and clinical efficacy of polymer-free sirolimus-eluting stents vs polymer-based paclitaxel-eluting stents remain a matter of debate. We sought to investigate angiographic and clinical measures of efficacy of polymer-free sirolimus-eluting stents vs polymer-based paclitaxel-eluting stents.

Methods

Patient data from the randomized intracoronary stenting and angiographic restenosis-test equivalence between the 2 drug-eluting stents (ISAR-TEST) clinical trial and the LIPSIA Yukon clinical trial (randomized comparison of a polymer-free sirolimus-eluting stent vs a polymer-based paclitaxel-eluting stent in patients with diabetes mellitus) were pooled. The angiographic (primary) endpoint was in-stent late lumen loss at 6 months to 9 months. The clinical (secondary) endpoints were death or myocardial infarction, cardiac death or myocardial infarction, target lesion revascularization, and myocardial infarction.

Results

A total of 686 patients (polymer-free sirolimus-eluting stents, n=345 vs polymer-based paclitaxel-eluting stents, n=341) and 751 lesions (polymer-free sirolimus-eluting stents, n=383 vs polymer-based paclitaxel-eluting stents, n=368) were included in the study. Control angiography (606 lesions, 80.6%) showed comparable in-stent late lumen loss for polymer-free sirolimus-eluting stents vs polymer-based paclitaxel-eluting stents (0,53 [0,59] mm vs 0,46 [0,57] mm; P=.15). Median follow-up was 34.8 months. Polymer-free sirolimus-eluting stents and polymer-based paclitaxel-eluting stents were associated with comparable risk of death or myocardial infarction (relative risk=1.17; 95% confidence interval, 0,49-2.80; P=.71), cardiac death or myocardial infarction (relative risk=1.17; 95% confidence interval, 0,72-1.89; P=.50), target lesion revascularization (relative risk=0,98; 95% confidence interval, 0,65-1.47; P=.93), and myocardial infarction (relative risk=1.79; 95% confidence interval, 0,85-3.76; P=.12).

Conclusions

In this pooled analysis, polymer-free sirolimus-eluting stents were comparable to polymer-based paclitaxel-eluting stents with respect to both angiographic and clinical efficacy.Full English text available from:www.revespcardiol.org.     

Rapid point-of-care NT-proBNP optimal cut-off point for heart failure diagnosis in primary care

Introduction and objectives

Measurement of natriuretic peptides may be recommended prior to echocardiography in patients with suspected heart failure. Cut-off point for heart failure diagnosis in primary care is not well established. We aimed to assess the optimal diagnostic cut-off value of N-terminal pro-B-type natriuretic peptide on a community population attended in primary care.

Methods

Prospective diagnostic accuracy study of a rapid point-of-care N-terminal pro-B-type natriuretic peptide test in a primary healthcare centre. Consecutive patients referred by their general practitioners to echocardiography due to suspected heart failure were included. Clinical history and physical examination based on Framingham criteria, electrocardiogram, chest X-ray, N-terminal pro-B-type natriuretic peptide measurement and echocardiogram were performed. Heart failure diagnosis was made by a cardiologist blinded to N-terminal pro-B-type natriuretic peptide value, using the European Society of Cardiology diagnosis criteria (clinical and echocardiographic data).

Results

Of 220 patients evaluated (65.5% women; median 74 years [interquartile range 67-81]). Heart failure diagnosis was confirmed in 52 patients (23.6%), 16 (30.8%) with left ventricular ejection fraction <50% (39.6 [5.1]%). Median values of N-terminal pro-B-type natriuretic peptide were 715 pg/mL [interquartile range 510.5-1575] and 77.5 pg/mL [interquartile range 58-179.75] for patients with and without heart failure respectively. The best cut-off point was 280 pg/mL, with a receiver operating characteristic curve of 0.94 (95% confidence interval, 0.91-0.97). Six patients with heart failure diagnosis (11.5%) had N-terminal pro-B-type natriuretic peptide values <400 pg/mL. Measurement of natriuretic peptides would avoid 67% of requested echocardiograms.

Conclusions

In a community population attended in primary care, the best cut-off point of N-terminal pro-B-type natriuretic peptide to rule out heart failure was 280 pg/mL. N-terminal pro-B-type natriuretic peptide measurement improve work-out diagnosys and could be cost-effectiveness.Full English text available from:www.revespcardiol.org